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This study underscores the critical importance of well-functioning sewer systems in achieving smart and sustainable urban drainage within cities. It specifically targets the pressing issue of sewer overflows (SO), widely recognized for their detrimental impact on the environment and public health. The primary purpose of this research is to bridge significant research gaps by investigating the root causes of SO incidents and comprehending their broader ecological consequences.

To fill research gaps, the study introduces the Multi-Phase Causal Inference Fuzzy-Based Framework (MCIF). MCIF integrates the fuzzy Delphi technique, fuzzy DEMATEL method, fuzzy TOPSIS technique and expert interviews. Drawing on expertise from developed countries, MCIF systematically identifies and prioritizes SO causes, explores causal interrelationships, prioritizes environmental impacts and compiles mitigation strategies.

The study's findings are multifaceted and substantially contribute to addressing SO challenges. Utilizing the MCIF, the research effectively identifies and prioritizes causal factors behind SO incidents, highlighting their relative significance. Additionally, it unravels intricate causal relationships among key factors such as blockages, flow velocity, infiltration and inflow, under-designed pipe diameter and pipe deformation, holes or collapse, providing a profound insight into the intricate web of influences leading to SO.

This study introduces originality by presenting the innovative MCIF tailored for SO mitigation. The combination of fuzzy techniques, expert input and holistic analysis enriches the existing knowledge. These findings pave the way for informed decision-making and proactive measures to achieve sustainable urban drainage systems.

Much work about health reform and systems improvement in healthcare looks at shortcomings and universal problems facing health systems, but rarely are accomplishments dissected and analyzed internationally. The purpose of this paper is to address this knowledge gap by examining the lessons learned from health system reform and improvement efforts in 60 countries.

In total, 60 low-, middle- and high-income countries provided a case study of successful health reform, which was gathered into a compendium as a recently published book. Here, the extensive source material was re-examined through inductive content analysis to derive broad themes of systems change internationally.

Nine themes were identified: improving policy, coverage and governance; enhancing the quality of care; keeping patients safe; regulating standards and accreditation; organizing care at the macro-level; organizing care at the meso- and micro-level; developing workforces and resources; harnessing technology and IT; and making collaboratives and partnerships work.

These themes provide a model of what constitutes successful systems change across a wide sample of health systems, offering a store of knowledge about how reformers and improvement initiators achieve their goals.

Few comparative international studies of health systems include a sufficiently wide selection of low-, middle- and high-income countries in their analysis. This paper provides a more balanced approach to consider where achievements are being made across healthcare, and what we can do to replicate and spread successful examples of systems change internationally.